A matrix model for valuing anesthesia service with the resource-based relative value system.

BACKGROUND: The purpose of this study was to propose a new crosswalk using the resource-based relative value system (RBRVS) that preserves the time unit component of the anesthesia service and disaggregates anesthesia billing into component parts (preoperative evaluation, intraoperative management, and postoperative evaluation). The study was designed as an observational chart and billing data review of current and proposed payments, in the setting of a preoperative holing area, intraoperative suite, and post anesthesia care unit. In total, 1,195 charts of American Society of Anesthesiology (ASA) physical status 1 through 5 patients were reviewed. No direct patient interventions were undertaken. RESULTS: Spearman correlations between the proposed RBRVS billing matrix payments and the current ASA relative value guide methodology payments were strong (r=0.94-0.96, P<0.001 for training, test, and overall). The proposed RBRVS-based billing matrix yielded payments that were 3.0%±1.34% less than would have been expected from commercial insurers, using standard rates for commercial ASA relative value units and RBRVS relative value units. Compared with current Medicare reimbursement under the ASA relative value guide, reimbursement would almost double when converting to an RBRVS billing model. The greatest increases in Medicare reimbursement between the current system and proposed billing model occurred as anesthetic management complexity increased. CONCLUSION: The new crosswalk correlates with existing evaluation and management and intensive care medicine codes in an essentially revenue neutral manner when applied to the market-based rates of commercial insurers. The new system more highly values delivery of care to more complex patients undergoing more complex surgery and better represents the true value of anesthetic case management.

Does the site of anterior tracheal puncture affect the success rate of retrograde intubation? A prospective, manikin-based study.

Background. Retrograde intubation is useful for obtaining endotracheal access when direct laryngoscopy proves difficult. The technique is a practical option in the "cannot intubate / can ventilate" scenario. However, it is equally useful as an elective technique in awake patients with anticipated difficult airways. Many practitioners report difficulty successfully advancing the endotracheal tube due to anatomical obstructions and the acute angle of the anterograde guide. The purpose of this study was to test whether a more caudal tracheal puncture would increase the success rate. Methods. Twenty-four anesthesiology residents were randomly assigned to either a cricothyroid or a cricotracheal puncture group. Each was instructed how to perform the technique and then attempted it on a manikin at their assigned site. Data collection included whether the trachea was intubated, the number of attempts required, and the total time. Results. Both groups displayed a high degree of success. While the group assigned to the cricotracheal site required significantly more time to perform the procedure, they accomplished it in fewer attempts than the cricothyroid group. Conclusion. Retrograde intubation performed via a cricotracheal puncture site, while more time consuming, resulted in fewer attempts to advance the endotracheal tube and may reduce in vivo laryngeal trauma.

Sedation and anesthesia options for pediatric patients in the radiation oncology suite.

External beam radiation therapy (XRT) has become one of the cornerstones in the management of pediatric oncology cases. While the procedure itself is painless, the anxiety it causes may necessitate the provision of sedation or anesthesia for the patient. This review paper will briefly review the XRT procedure itself so that the anesthesia provider has an understanding of what is occurring during the simulation and treatment phases. We will then examine several currently used regimens for the provision of pediatric sedation in the XRT suite as well as a discussion of when and how general anesthesia should be performed if deemed necessary. Standards of care with respect to patient monitoring will be addressed. We will conclude with a survey of the developing field of radiation-based therapy administered outside of the XRT suite.

Monitored anesthesia care (MAC) sedation: clinical utility of fospropofol.

Fospropofol, a phosphorylated prodrug version of the popular induction agent propofol, is hydrolyzed in vivo to release active propofol, formaldehyde, and phosphate. Pharmacodynamic studies show fospropofol provides clinically useful sedation and EEG/bispectral index suppression while causing significantly less respiratory depression than propofol. Pain at the injection site, a common complaint with propofol, was not reported with fospropofol; the major patient complaint was transitory perianal itching during the drug's administration. Although many clinicians believe fospropofol can safely be given by a registered nurse, the FDA mandated that fospropofol, like propofol, must be used only in the presence of a trained anesthesia provider.

Endotracheal tube malposition within the pediatric population: a common event despite clinical evidence of correct placement.

PURPOSE: To ensure that the endotracheal tube (ETT) is ideally placed for proper ventilation, radiographic confirmation of ETT placement is frequently used to supplement clinical examination in the intensive care unit setting. However, fluoroscopy rarely serves the same role during surgery, despite the fact that portable units are often present in the operating room. The purpose of this study was to ascertain the value of fluoroscopy in determining ETT malposition among the pediatric surgical population. METHODS: Chest radiographs from 257 children (age 12 days-12 yr), who presented for a total of 446 individual procedures in the fluoroscopy suite, were studied to determine the incidence of ETTs placed too shallow (above the inferior clavicular border) or too deep (at or below the carina). A logistic regression with outcomes of correct and incorrect was used to analyze the data points. RESULTS: Eighteen percent of all the radiographs showed initial improper ETT placement, despite clinical evidence suggesting the contrary. The peak incidence of malposition, which occurred in patients under one year old, reached 35%. Incidence decreased with advancing age, but remained over 10% until the age of ten. A second attempt at positioning the tube, based on information from the chest radiograph, was successful in 95% of the cases. The remaining 5% required placement of the ETT under continuous fluoroscopic guidance. CONCLUSION: Fluoroscopy, when readily available in the operating room, is a safe and useful technique to ensure proper ETT placement among the pediatric population.

Can you keep a secret? Confidentiality in psychotherapy.

Confidentiality is the secret-keeping duty that arises from the establishment of the professional relationship psychologists develop with their clients. It is a duty created by the professional relationship, it is set forth in the American Psychological Association's (2002) Ethical Principles and Code of Conduct, and it is codified in many state regulations. However, the difference between confidentiality and legal privilege; how, why, and when it can be violated; and the reasons for so doing are not well understood by many practitioners. While on the surface confidentiality might seem to be an easy concept to apply to professional practice, in fact it is quite complex and filled with exceptions that frequently differ from circumstance to circumstance and from state to state. A lack of respect for and a lack of familiarity with the significance of these exceptions could have dire professional consequences. This article reviews the ethical imperative of confidentiality and then provides examples of legal cases that help to better understand its complexity. Then, we offer strategies designed to help metal health practitioners when they are confronted with questions regarding confidentiality and privilege.

Reoperation on the abdomen encased in adhesions.

PURPOSE: To determine outcome after lysis of intestinal adhesions, relief of obstruction, closure of fistulas and drainage of abscesses in patients with an abdominal cavity obliterated by chronic postoperative adhesions. METHODS: Among 40 patients with an abdomen encased in dense adhesions after a mean of 5 previous operations, 31 patients also had intestinal obstruction, 25 enteric fistulas and 20 abdominal abscesses. Reoperation was done and outcome assessed from the medical records and by a mailed questionnaire. RESULTS: Only 1 postoperative death occurred, but 24 early complications appeared. At hospital discharge, obstruction, fistula and abscess were completely resolved in all but 3 patients (P <0.001). Only 2 of 16 patients on parenteral nutrition before operation (TPN) still required it (P = 0.004). At late follow-up (mean, 4.6 years) the patients' quality of life (mean score +/- SD, 8.6 +/- 2.1) was similar to that of a healthy control population (9.2 +/- 1.2, P = 0.17). CONCLUSIONS: Reoperation on the abdomen encased in adhesions restores most patients to good health and an excellent long-term quality of life.